Pulse oximetry data confidence indicator

ABSTRACT

An intelligent, rule-based processor provides a pulse indicator designating the occurrence of each pulse in a pulse oximeter-derived photo-plethysmograph waveform. When there is relatively no distortion corrupting the plethysmograph signal, the processor analyzes the shape of the pulses in the waveform to determine where in the waveform to generate the pulse indication. When distortion is present, looser waveform criteria are used to determine if pulses are present. If pulses are present, the pulse indication is based upon an averaged pulse rate. If no pulses are present, no indication occurs. The pulse indicator provides a trigger and amplitude output. The trigger output is used to initiate an audible tone “beep” or a visual pulse indication on a display, such as a vertical spike on a horizontal trace or a corresponding indication on a bar display. The amplitude output is used to indicate data integrity and corresponding confidence in the computed values of saturation and pulse rate. The amplitude output can vary a characteristic of the pulse indicator, such as beep volume or frequency or the height of the visual display spike. 
     The visual pulse indicator is supplemented by a signal quality alert. Combined with several indicators of signal quality, the alert is used to initiate a warning when data confidence is very low. The alert may be in the form of a message generated on the pulse oximeter display to warn that the accuracy of saturation and pulse rate measurements may be compromised. A confidence-based alarm utilizes signal quality measures to reduce the probability of false alarms when data confidence is low and to reduce the probability of missed events when data confidence is high.

This is a continuation-in-part of U.S. patent application Ser. No.09/478,230 entitled “Pulse Oximetry Pulse Indicator,” filed Jan. 6,2000, which relates to and claims the benefit of prior provisionalapplication 60/115,289, filed Jan. 7, 1999.

BACKGROUND OF THE INVENTION

Oximetry is the measurement of the oxygen status of blood. Earlydetection of low blood oxygen is critical in the medical field, forexample in critical care and surgical applications, because aninsufficient supply of oxygen can result in brain damage and death in amatter of minutes. Pulse oximetry is a widely accepted noninvasiveprocedure for measuring the oxygen saturation level of arterial blood,an indicator of oxygen supply. A pulse oximeter typically provides anumerical readout of the patient's oxygen saturation, a numericalreadout of pulse rate, and an audible indicator or “beep” that occurs inresponse to each pulse. In addition, a pulse oximeter may display thepatient's plethysmograph waveform, which is a visualization of bloodvolume change in the illuminated tissue caused by pulsatile arterialblood flow over time. The plethysmograph provides a visual display thatis also indicative of the patient's pulse and pulse rate.

A pulse oximetry system consists of a sensor attached to a patient, amonitor, and a cable connecting the sensor and monitor. Conventionally,a pulse oximetry sensor has both red and infrared (IR) light-emittingdiode (LED) emitters and a photodiode detector. The sensor is typicallyattached to a patient's finger or toe, or a very young patient'spatient's foot. For a finger, the sensor is configured so that theemitters project light through the fingernail and into the blood vesselsand capillaries underneath. The photodiode is positioned at thefingertip opposite the fingernail so as to detect the LED transmittedlight as it emerges from the finger tissues.

The pulse oximetry monitor (pulse oximeter) determines oxygen saturationby computing the differential absorption by arterial blood of the twowavelengths emitted by the sensor. The pulse oximeter alternatelyactivates the sensor LED emitters and reads the resulting currentgenerated by the photodiode detector. This current is proportional tothe intensity of the detected light. The pulse oximeter calculates aratio of detected red and infrared intensities, and an arterial oxygensaturation value is empirically determined based on the ratio obtained.The pulse oximeter contains circuitry for controlling the sensor,processing the sensor signals and displaying the patient's oxygensaturation and pulse rate. A pulse oximeter is described in U.S. Pat.No. 5,632,272 assigned to the assignee of the present invention.

SUMMARY OF THE INVENTION

FIG. 1 illustrates the standard plethysmograph waveform 100, which canbe derived from a pulse oximeter. The waveform 100 is a display of bloodvolume, shown along the y-axis 110, over time, shown along the x-axis120. The shape of the plethysmograph waveform 100 is a function ofphysiological conditions including heart stroke volume, pressuregradient, arterial elasticity and peripheral resistance. The idealwaveform 100 displays a broad peripheral flow curve, with a short, steepinflow phase 130 followed by a 3 to 4 times longer outflow phase 140.The inflow phase 130 is the result of tissue distention by the rapidblood volume inflow during ventricular systole. During the outflow phase140, blood flow continues into the vascular bed during diastole. The enddiastolic baseline 150 indicates the minimum basal tissue perfusion.During the outflow phase 140 is a dicrotic notch 160, the nature ofwhich is disputed. Classically, the dicrotic notch 160 is attributed toclosure of the aortic valve at the end of ventricular systole. However,it may also be the result of reflection from the periphery of aninitial, fast propagating, pressure pulse that occurs upon the openingof the aortic valve and that precedes the arterial flow wave. A doubledicrotic notch can sometimes be observed, although its explanation isobscure, possibly the result of reflections reaching the sensor atdifferent times.

FIGS. 2-4 illustrate plethysmograph waveforms 200, 310, 360 that displayvarious anomalies. In FIG. 2, the waveform 200 displays two arrhythmias210, 220. In FIG. 3, the waveform 310 illustrates distortion corruptinga conventional plethysmograph 100 (FIG. 1). FIG. 4 shows a filteredwaveform 360 after distortion has been removed through adaptivefiltering, such as described in U.S. Pat. No. 5,632,272 cited above.FIG. 4 illustrates that, although the waveform 360 is filtered, theresulting pulses 362 have shapes that are distorted in comparison to thepulses illustrated in FIG. 1.

A desirable feature of pulse oximeters is an audible “beep” toneproduced to correspond to the patient's pulse. Conventionally, the beepis triggered from recognition of some aspect of the plethysmographwaveform shape. Such a waveform-triggered beep may indicate anarrhythmia, like those displayed in FIG. 2, but may also generate falsepulse indications as the result of motion-artifact or noise inducedwaveform distortion, as illustrated in FIGS. 3 and 4. Thischaracteristic results because both distortion and arrhythmias result inanomalies in the plethysmograph waveform shape on which this beepmechanism is dependent. Alternatively, the beep can be triggered from atime base set to the average pulse rate. Signal processing can generatean average pulse rate that is resistant to distortion induced error. Apulse beep based on average pulse rate is relatively insensitive toepisodes of distortion, but is likewise insensitive to arrhythmias.

An example of the determination of pulse rate in the presence ofdistortion is described in U.S. Pat. No. 6,002,952, filed Apr. 14, 1997,entitled “Signal Processing Apparatus and Method,” which is assigned tothe assignee of the current application and incorporated by referenceherein. Another example of pulse rate determination in the presence ofdistortion is described in U.S. patent application Ser. No. 09/471,510,filed Dec. 23, 1999, entitled “Plethysmograph Pulse RecognitionProcessor,” which is assigned to the assignee of the current applicationand incorporated by reference herein.

One aspect of the present invention is a processor having a decisionelement that determines if the waveform has little or no distortion orsignificant distortion. If there is little distortion, the decisionelement provides a trigger in real-time with physiologically acceptablepulses recognized by a waveform analyzer. If there is significantdistortion, then the decision element provides the trigger basedsynchronized to an averaged pulse rate, provided waveform pulses aredetected. The trigger can be used to generate an audible pulse beep thatis insensitive to episodes of significant distortion, but is capable ofresponding to arrhythmia events.

Another desirable feature for pulse oximeters is a visual indication ofthe patient's pulse. Conventionally, this is provided by anamplitude-versus-time display of the plethysmograph waveform, such asillustrated in FIG. 1. Some monitors are only capable of a light-bardisplay of the plethysmograph amplitude. Regardless, both types ofdisplays provide a sufficient indication of the patient's pulse onlywhen there is relatively small distortion of the plethysmographwaveform. When there is significant distortion, such as illustrated inFIG. 3A, the display provides practically no information regarding thepatient's pulse.

Yet another desirable feature for pulse oximeters is an indication ofconfidence in the input data. Conventionally, a visual display of aplethysmograph waveform that shows relatively small distortion wouldconvey a high confidence level in the input data and a correspondinghigh confidence in the saturation and pulse rate outputs of the pulseoximeter. However, a distorted waveform does not necessarily indicatelow confidence in the input data and resulting saturation and pulse rateoutputs, especially if the pulse oximeter is designed to function in thepresence of motion-artifact.

Another aspect of the current invention is the generation of a dataintegrity indicator that is used in conjunction with the decisionelement trigger referenced above to create a visual pulse indicator. Thevisual pulse indicator is an amplitude-versus-time display that can beprovided in conjunction with the plethysmograph waveform display. Thetrigger is used to generate a amplitude spike synchronous to aplethysmograph pulse. The data integrity indicator varies the amplitudeof the spike in proportion to confidence in the measured values.

Yet another aspect of the present invention is a processing apparatusthat has as an input a plethysmograph waveform containing a plurality ofpulses. The processor generates a trigger synchronous with theoccurrence of the pulses. The processor includes a waveform analyzerhaving the waveform as an input and responsive to the shape of thepulses. The processor also includes a decision element responsive to thewaveform analyzer output when the waveform is substantially undistortedand responsive to pulse rate when the waveform is substantiallydistorted. The trigger can be used to generate an audible or visualindicator of pulse occurrence. A measure of data integrity can also beused to vary the audible or visual indicators to provide a simultaneousindication of confidence in measured values, such as oxygen saturationand pulse rate.

A further aspect of the current invention is a method of indicating apulse in a plethysmograph waveform. The method includes the steps ofderiving a measure of distortion in the waveform, establishing a triggercriterion dependent on that measure, determining whether the triggercriterion is satisfied to provide a trigger, and generating a pulseindication upon occurrence of the trigger. The deriving step includesthe substeps of computing a first value related to the waveformintegrity, computing a second value related to the recognizable pulsesin the waveform, and combining the first and second values to derive thedistortion measure. The trigger criterion is based on waveform shape andpossibly on an averaged pulse rate.

One more aspect of the current invention is an apparatus for indicatingthe occurrence of pulses in a plethysmograph waveform. This apparatusincludes a waveform analyzer means for recognizing a physiological pulsein the waveform. Also included is a detector means for determining ameasure of distortion in the waveform and a decision means fortriggering an audible or visual pulse indicator. The decision means isbased the physiological pulse and possibly the pulse rate, depending onthe distortion measure.

Another aspect of the present invention is a data confidence indicatorcomprising a plurality of physiological data and a plurality of signalquality measures derived from a physiological sensor output. A pluralityof comparator outputs are each responsive to one of the measures and acorresponding one of a plurality of thresholds. An alert trigger outputcombines said comparator outputs, and a low signal quality warning isgenerated in response to said alert trigger output. The thresholds areset so that the warning occurs during a time period when there is lowconfidence in the data. In one embodiment, the warning is a displaymessage that supplements a visual pulse indicator, the display messagespecifies a low signal quality when the visual pulse indicator has anamplitude that is less than one-third full-scale. In another embodiment,the signal quality measures are an integrity measure, a pulse ratedensity measure and a harmonic ratio measure. In a particularembodiment, the thresholds may have an integrity value of less than 0.3,a pulse rate density value of less than 0.7 and a harmonic ratio valueof less than 0.8.

In yet another embodiment a filter for the data generates a smootheddata output. An adjustment for the smoothed data output is a function ofat least one of the signal quality measures so that smoothing at thesmoothed data output increases when at least one of the signal qualitymeasures decreases. An alarm trigger is responsive to the smoothed dataoutput so as to generate an alarm when the smoothed data output isoutside of a predetermined limit. In a particular embodiment the filtercomprises a buffer having a buffer input and a delay output. The bufferinput corresponds to the data and the delay output is time-shiftedaccording to the adjustment. A first filter comparator output isresponsive to the data and a data threshold, and a second filtercomparator output is responsive to the delay output and a delay outputthreshold. The comparator outputs are combined so as to provide thealarm trigger.

A further aspect of the present invention is a data confidence indicatorcomprising a processor configured to derive a time-dependentphysiological data set and a plurality of time-dependent signal qualitymeasures from a physiological signal. A buffer is configured totime-shift the data set by a delay to generate a delayed data set, wherethe delay is a function of at least one of the signal quality measures.The indicator has a threshold setting a limit for the delayed data set.A warning is generated when the levels of the data set and the delayeddata set are beyond that threshold. In one embodiment, a firstcomparator output is responsive to the data and the threshold, and asecond comparator output is responsive to the delayed data set and thethreshold. A combination of the first and second comparator outputsprovides an alarm trigger for the warning. The data confidence indicatormay also comprise a combination of the signal quality measures providingan alert trigger to generate warning when confidence in the data set islow.

An additional aspect of the present invention is a data confidenceindication method comprising the steps of acquiring a signal from aphysiological sensor, calculating a physiological data set from thesignal, calculating signal quality measures from the signal, andindicating on a display the confidence in the data set based upon atleast one of the signal quality measures. The indicating step may havethe substeps of utilizing the signal quality measures to detect a lowsignal quality period during which time the data set may be compromised,and writing an alert message on the display during at least a portion ofthat period. Additional utilizing substeps may include comparing each ofthe signal quality measures to a corresponding one of a plurality ofthresholds to generate a plurality of trigger inputs and combining thetrigger inputs to trigger a low signal quality warning. Additional stepsmay include setting an alarm limit for the data set, filtering the dataset to generate an alarm trigger based upon the alarm limit andadjusting the characteristics of the filtering step according to atleast one of the signal quality measures so that more filtering isapplied during the low signal quality period. In one embodiment, thefiltering step comprises the substeps of time-shifting the data set tocreate a delayed data set, comparing the data set to a threshold togenerate a first trigger input, comparing the delayed data set to thethreshold to generate a second trigger input, and combining the triggerinputs to generate the alarm trigger.

Yet a further aspect of the present invention is a data confidenceindication method comprising the steps of acquiring a signal from aphysiological sensor, calculating a physiological data set from thesignal, calculating a plurality of signal quality measures from thesignal, setting an alarm threshold for the data set, and delaying analarm trigger when the data set exceeds the threshold as a function ofat least one of the signal quality measures so as to reduce theprobability of false alarms. In one embodiment, the delaying stepcomprises the substeps of time-shifting the data set by a delay togenerate a delayed data set, where the delay is a function of at leastone of said signal quality measures, and comparing the data set to thethreshold to create a first limit output. Further substeps includecomparing the delayed data set to the threshold to create a second limitoutput and combining the limit outputs to generate the alarm trigger.The data confidence indication method may further comprise the steps ofcomparing each of the signal quality measures to a corresponding one ofa plurality of thresholds to generate a plurality of trigger inputs andcombining the trigger inputs to trigger a low signal quality warning.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a standard plethysmograph waveform that can bederived from a pulse oximeter;

FIG. 2 illustrates a plethysmograph waveform showing an arrhythmia;

FIG. 3A illustrates a plethysmograph waveform corrupted by distortion;

FIG. 3B illustrates a filtered plethysmograph corresponding to thedistortion-corrupted plethysmograph of FIG. 3A;

FIG. 4 illustrates the inputs and outputs of the pulse indicatoraccording to the present invention;

FIG. 5 illustrates the generation of one of the pulse indicator inputs;

FIG. 6 is a top-level block diagram of the pulse indicator;

FIG. 7 is a detailed block diagram of the “distortion level” portion ofthe pulse indicator;

FIG. 8 is a block diagram of the infinite impulse response (IIR) filtersof the “distortion level” portion illustrated in FIG. 7;

FIG. 9 is a detailed block diagram of the “waveform analyzer” portion ofthe pulse indicator;

FIG. 10 is a detailed block diagram of the “slope calculator” portion ofthe waveform analyzer illustrated in FIG. 9;

FIG. 11 is a detailed block diagram of the “indicator decision” portionof the pulse indicator;

FIG. 12 is a display illustrating a normal plethysmograph and acorresponding visual pulse indicator;

FIG. 13 is a display illustrating a distorted plethysmograph and acorresponding high-confidence-level visual pulse indicator;

FIG. 14 is a display illustrating a distorted plethysmograph and acorresponding low-confidence-level visual pulse indicator;

FIG. 15 is an input and output block diagram of a signal quality alert;

FIG. 16 is a functional block diagram of a signal quality alert;

FIG. 17 is an input and output block diagram of a confidence-basedalarm;

FIG. 18 is a functional block diagram of a confidence-based alarm; and

FIGS. 19A-D are saturation versus time graphs illustrating operation ofa confidence-based alarm.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

FIG. 4 illustrates a pulse indicator 400, which can be incorporated intoa pulse oximeter to trigger the occurrence of a synchronous indicationof each of the patient's arterial pulses. The indicator 400 operates onan IR signal input 403 and generates a trigger output 409 and anamplitude output 410. The trigger output 409 can be connected to a tonegenerator within the pulse oximeter monitor to create a fixed-durationaudible “beep” as a pulse indication. Alternatively, or in addition, thetrigger output can be connected to a display generator within the pulseoximeter monitor to create a visual pulse indication. The visual pulseindication can be a continuous horizontal trace on a CRT, LCD display orsimilar display device, where vertical spikes occur in the tracesynchronously with the patient's pulse, as described in more detailbelow. Alternatively, the visual pulse indication can be a bar display,such as a vertically- or horizontally-arranged stack of LEDs or similardisplay device, where the bar pulses synchronously with the patient'spulse.

The amplitude output 410 is used to vary the audible or visualindications so as to designate input data integrity and a correspondingconfidence in the saturation and pulse rate outputs of the pulseoximeter. For example, the height of the vertical spike can be varied inproportion to the amplitude output 410, where a large or small verticalspike would correspondingly designate high or low confidence. As anotherexample, the amplitude output 410 can be used to vary the volume of theaudible beep or to change the visual indication (e.g., change color orthe like) to similarly designate a high or low confidence. One ofordinary skill in the art will recognize that the trigger output 409 andamplitude output 410 can be utilized to generate a variety of audibleand visual indications of a patient's pulse and data integrity withinthe scope of this invention.

Other inputs to the pulse indicator 400 include pulse rate 401, Integ404, PR density 405, patient type 406 and reset 408, which are describedin detail below. The beep decision involves a rule-based process thatadvantageously responds to the pulse waveforms of the patient'splethysmograph in low-noise or no-distortion situations, but becomesdependent an averaged pulse rate during high-noise or distortionsituations. This “intelligent beep” reliably indicates the patient'spulse, yet responds to patient arrhythmias, asystole conditions andsimilar irregular plethysmographs.

The pulse rate input 401 to the pulse indicator 400 provides thefrequency of the patient's pulse rate in beats per minute. Pulse ratecan be determined as described in U.S. Pat. No. 6,002,952 “SignalProcessing Apparatus and Method” or U.S. patent application Ser. No.09/471,510 “Plethysmograph Pulse Recognition Processor,” both citedabove.

FIG. 5A illustrates the generation of the Integ input 404 to the pulseindicator 400 (FIG. 4). The IR 403 and Red 502 signals derived from apulse oximetry sensor are input to an adaptive noise canceller 500having Integ 404 as an output. The Integ output 404 is a measure of theintegrity of the IR 403 and Red 502 input signals.

FIG. 5B illustrates the adaptive noise canceller 500. The referenceinput 502 is processed by an adaptive filter 520 that automaticallyadjusts its own impulse response through a least-squares algorithm. Theleast-squares algorithm responds to an error signal 512 that is thedifference 510 between the noise canceller input 403 and the adaptivefilter output 522. The adaptive filter is adjusted through the algorithmto minimize the power at the noise canceller output 404. If the IR 403and Red 502 signals are relatively well-behaved with respect to thetheoretical model for these signals, then the noise canceller output 404will be relatively small. This model assumes that the same frequenciesare present in the signal and noise portions of the IR and Red signals.By contrast, if a phenomenon such as scattering, hardware noise, orsensor decoupling, to name a few, affects one input signal differentlythan the other, then the power at the noise canceller output will berelatively large. More detail about the input signal model and theadaptive noise canceller 500 is given in U.S. Pat. No. 5,632,272entitled “Signal Processing Apparatus,” issued May 27, 1997, assigned tothe assignee of the current application and incorporated by referenceherein.

The PR density input 405 is a ratio of the sum of the periods ofrecognizable pulses within a waveform segment divided by the length ofthe waveform segment. This parameter represents the fraction of thewaveform segment that can be classified as having physiologicallyacceptable pulses. In one embodiment, a segment represents a snapshot of400 samples of a filtered input waveform, or a 6.4 second “snapshot” ofthe IR waveform at a 62.5 Hz sampling rate. The derivation of PR densityis described in the U.S. patent application Ser. No. 09/471,510 entitled“Plethysmograph Pulse Recognition Processor,” cited above.

Other inputs to the pulse indicator 400 are the IR input 403, patienttype 406 and reset 408. The IR input 403 is the detected IR signalpreprocessed by taking the natural logarithm, bandpass filtering andscaling in order to normalize the signal and remove the direct currentcomponent, as is well known in the art. Patient type 406 is a Booleanvalue that indicates either an adult sensor or a neonate sensor is inuse. Reset 408 initializes the state of the pulse indicator 400 to knownvalues upon power-up and during periods of recalibration, such as when anew sensor is attached or a patient cable is reconnected.

FIG. 6 is a functional block diagram of the pulse indicator 400. Thepulse indicator 400 includes a shifting buffer 610, a distortion levelfunction 620, a waveform analyzer 630, and a indicator decision 640,which together produce the indicator trigger 409. The pulse indicator400 also includes a scaled logarithm function 650 that produces theindicator amplitude output 410. The shifting buffer 610 accepts the IRinput 403 and provides a vector output 612 representing a fixed-sizesegment of the patient's plethysmograph input to the waveform analyzer630. In a particular embodiment, the output vector is a 19 samplesegment of the IR input 403. This waveform segment size represents atradeoff between reducing the delay from pulse occurrence to pulseindicator, which is equal to 0.304 seconds at the 62.5 Hz input samplerate, yet providing a sufficiently large waveform segment to analyze.This fixed-sized segment is updated with each new input sample, and anew vector is provided to the waveform analyzer 630 accordingly.

The distortion level function 620 determines the amount of distortionpresent in the IR input signal 403. The inputs to the distortion levelfunction 620 are the Integ input 404 and the PR density input 405. Thedistortion output 622 is a Boolean value that is “true” when distortionin the IR input 403 is above a predetermined threshold. The distortionoutput 622 is input to the waveform analyzer 630 and the indicatordecision 640. The distortion output 622 determines the thresholds forthe waveform analyzer 630, as described below. The distortion output 622also affects the window size within which a pulse indication can occur,also described below. The distortion output 622 is also a function ofthe patient type input 406, which indicates whether the patient is anadult or a neonate. The reason for this dependence is also describedbelow.

The waveform analyzer 630 determines whether a particular portion of theIR input 403 is an acceptable place for a pulse indication. The input tothe waveform analyzer 630 is the vector output 612 from the shiftingbuffer 610, creating a waveform segment. A waveform segment portionmeets the acceptance criteria for a pulse when it satisfies one of threeconditions. These conditions are a sharp downward edge, a peak in themiddle with symmetry with respect to the peak, and a peak in the middlewith a gradual decline. If one of these criteria is met, the waveformanalyzer “quality” output 632 is “true.” Different criteria are applieddepending on the state of the distortion output 622, which is also awaveform analyzer input. If the distortion output 622 indicates nodistortion, strict criteria are applied to the waveform shape. If thedistortion output 622 indicates distortion, looser criteria are appliedto the waveform shape. Different criteria are also applied for waveformsobtained from adult and neonate patients, as indicated by the patienttype 406. The specific criteria are described in further detail below.

The indicator decision 640 determines whether to trigger a pulseindication at a particular sample point of the input waveform.Specifically, the indicator decision 640 determines if it is the rightplace to trigger a pulse indication on the input waveform and if thetime from the last pulse indication was long enough so that it is theright time to trigger another pulse indication. The decision as to theright place to trigger a pulse indication is a function of the analyzeroutput 632, which is one input to the indicator decision 640. Thedecision as to the right time for an indicator trigger is a function ofthe state of the distortion output 622, which is another input to theindicator decision 640. If the distortion output 622 is “false”, i.e. nodistortion is detected in the input waveform, then a fixed minimum timegap from the last indicator must occur. In a particular embodiment, thisminimum time gap is 10 samples. If the distortion output 622 is “true”,i.e. distortion is detected in the input waveform, then the minimum timegap is a function of the pulse rate input 401. This pulse rate dependentthreshold is described in further detail below.

FIG. 7 is a detailed block diagram of the distortion level function 620.The distortion level function has two stages. The first stage 702filters the Integ and PR density inputs. The second stage 704 decideswhether distortion is present based on both the filtered and theunfiltered Integ input 404 and PR density 405 inputs. The first stagecomponents are a first infinite impulse response (IIR) filter 710 forthe Integ input 404 and a second IIR filter 720 for the PR density input405.

FIG. 8 illustrates the structure of the IIR filter 710, 720 (FIG. 7).Each of these filters has a delay element 810, which provides a onesample delay from the delay element input 812 to the delay elementoutput 814. An adder 820 that sums a weighted input value 834 and aweighted feedback value 844 provides the delay element input 812. Afirst multiplier 830 generates the weighted input value 834 from theproduct of the input 802 and a first constant 832, c₁. A secondmultiplier 840 generates the weighted feedback value 844 from theproduct of the delay element output 814 and a second constant 842, c₂.With this structure, the filter output 804 is:

Output _(n) =c ₁ ·Input _(n) +c ₂ ·Output _(n−1)  (1)

That is, the nth output 804 is the weighted average of the input and theprevious output, the amount of averaging being determined by therelative values of c₁ and c₂.

As shown in FIG. 7, the two IIR filters 710, 720 each apply differentrelative weights to the input signal. In one embodiment, the weights arefixed for the Integ filter 710 and are a function of the patient typefor the PR density filter 720. In particular, for the Integ filter 710,c₁=0.2 and c₂ =0.8. For the PR density filter 720, the combination of amultiplexer 730 and subtraction 740 set the values of c₁ and c₂ as afunction of the patient type 406. If the signal is from an adult, thenc₁=0.2 and c₂=0.8. If the signal is from a neonate, then c₁=0.5, c₂=0.5. Because a neonate pulse rate is typically higher than an adult,the PR density changes less quickly and, hence, less filtering isapplied.

FIG. 7 also shows the second stage 704, which has threshold logic 750for determining the presence of distortion. The inputs to the thresholdlogic 750 are Integ 404, PR density 405, filtered Integ 712 and filteredPR density 722. The threshold logic 750 is also dependent on the patienttype 406. The distortion output 622 is a Boolean value that is “true” ifdistortion is present and “false” if no distortion is present. In oneembodiment, the distortion output 622 is calculated as follows:

Adults

distortion output=(Integ>0.01)+(filtered Integ>0.0001)·(filtered PRdensity<0.7)  (2)

Neonates

distortion output=(Integ>0.05)+((filter Integ>0.005)+(PRdensity=0))·(filtered PR density<0.8)  (3)

where a logical “and” is designated as a multiplication “·” and alogical “inclusive or” is designated as an addition “+.”

FIG. 9 is a detailed block diagram of the waveform analyzer 630. Asdescribed above, the waveform analyzer 630 is based on three shapecriteria, which are implemented with a sharp downward edge detector 910,a symmetrical peak detector 920 and a gradual decline detector 930. An“or” function 940 generates a waveform analyzer output 632, which has a“true” value if any of these criteria are met. The inputs to thewaveform analyzer 630 are the IR waveform samples 612 from the buffer610 (FIG. 6), patient type 406, and distortion 622 output from thedistortion level function 620 (FIG. 6). The IR waveform samples 612 area 19 sample vector representing a plethysmograph waveform segment. Aslope calculator 950 and a peak/slope detector 960 provide inputs to theshape criteria components 910, 920, 930.

Shown in FIG. 10, the slope calculator 950 operates on the IR waveformsamples 612 to calculate a down slope value, which is provided on a downslope output 952, and an up slope value, which is provided on an upslope output 954. The down slope and up slope values are defined to be,respectively, the difference between the middle point and the last andfirst points, scaled by a factor of 62.5/9. The scaling factor is thesampling rate, 62.5 Hz, divided by the number of samples, 9, between themiddle point and end point in the 19 sample IR waveform 612. The slopecalculator 950 has an element selector 1010 that determines the centersample, the extreme left sample and the extreme right sample from the IRwaveform 612. The block-to-scalars function 1020 provides a left sampleoutput 1022 and a center sample output 1024 to a first subtractor 1030and the center sample output 1024 and a right sample output 1028 to asecond subtractor 1040. The first subtractor output 1032, which is thecenter value minus the right sample value, is scaled by 62.5/9 by afirst multiplier 1050 that generates the down slope output 952. Thesecond subtractor output 1042, which is the center value minus the leftsample value, is scaled by 62.5/9 by a second multiplier 1060 thatgenerates the up slope output 954.

Shown in FIG. 9, the peak/slope detector 960, like the slope calculator950 has the IR waveform samples 612 as an input. The peak/slope detector960 has two Boolean outputs, a peak output 962 and a slope output 964.The peak output 962 is “true” if the input waveform contains a peak. Theslope output 964 is “true” if the input waveform contains a slope. Thepeak output 962 and slope output 964 are also dependent on the patienttype 406 to the peak/slope detector 960. In one embodiment, the peakoutput 962 and slope output 964 are calculated as follows:

Adults

peak output=(In ₉>0)Π³ _(i=1)(In ₇ −In _(7−i)>0)Π⁹ _(i=3)(In ₉ −In_(9+i)>−0.005)  (4)

slope output=(In ₉>0)Π¹⁸ _(i=3)(In _(i−1) −In _(i)>−0.005)  (5)

Neonates

peak output=Π³ _(i=1)(In ₇ −In _(7−i)>0)Π⁹ _(i=3)(In ₉ −In_(9+i)>−0.005)  (6)

slope output=Π¹⁸ _(i=3)(In _(i−1) −In _(i)>−0.005)  (7)

where In_(i) is the ith waveform sample in the 19 sample IR waveform612.

FIG. 9 shows the sharp downward edge detector 910, which is thesub-component of the waveform analyzer 630 that determines whether theshape of the input waveform segment meets the sharp downward edgecriteria. To do this, the edge detector 910 determines whether the downslope value is bigger than a certain threshold and whether a peak ispresent. The edge detector 910 has as inputs the down slope output 952from the slope calculator 950, the peak output 962 from the slope/peakdetector 960, the distortion output 622 from the distortion levelfunction 620 (FIG. 6) and the patient type 406. The edge detector output912 is a Boolean value that is “true” when the waveform shape criteriais met. In one embodiment, the edge detector output 912 is calculated asfollows:

Adults and No Distortion

edge output=(down slope output>3)·peak output  (8)

Neonates and No Distortion

edge output=(down slope value>1)·peak output  (9)

Distortion (Adults or Neonates)

edge output=(down slope value>0.65)·peak output  (10)

FIG. 9 also shows the symmetrical peak detector 920, which is thesub-component of the waveform analyzer 630 that determines whether thewaveform contains a symmetrical peak. To do this, the symmetrical peakdetector 920 checks whether the down slope and up slope values arebigger than a certain threshold, if the difference between theirmagnitudes is small, and if a peak is present. The symmetrical peakdetector 920 has as inputs the down slope output 952 and the up slopeoutput 954 from the slope calculator 950, the peak output 962 from theslope/peak detector 960, the distortion output 622 from the distortionlevel function 620 (FIG. 6) and the patient type 406. The symmetricalpeak output 922 is a Boolean value that is “true” when the waveformshape criteria is met. In one embodiment, the symmetrical peak output922 is defined as follows:

Adults

symmetrical peak output=false  (11)

Neonates and No Distortion

symmetrical peak output=(down slope>1)·(up slope>1)·(|down slope−upslope|≦0.5)·peak  (12)

Neonates and Distortion

symmetrical peak output=(down slope>0.35)·(up slope>0.35)·(|downslope−up slope|≦0.5)·peak  (13)

FIG. 9 further shows the gradual decline detector 930, which is thesub-component of the waveform analyzer 630 that determines whether thewaveform contains a gradual decline. To do this, the decline detector930 checks whether the difference between the down slope and the upslope values is in between two thresholds and if a slope is present. Thedecline detector 930 has as inputs the down slope output 952 and the upslope output 954 from the slope calculator 950, the slope output 964from the slope/peak detector 960, the distortion output 622 from thedistortion level function 620 (FIG. 6) and the patient type 406. Thedecline output 932 is a Boolean value that is “true” when the waveformshape criteria is met. In one embodiment, the decline output 932 isdefined as follows:

Adults and No Distortion

decline=(3<(down slope−up slope)<6)·slope  (14)

Neonates and No Distortion

decline=(0.5<(down slope−up slope)<2)·slope  15)

Distortion (Adults or Neonates)

decline=(0.5<(down slope−up slope)<8)·slope  (16)

FIG. 11 is a detailed block diagram of the indicator decision 640sub-component. The first stage 1102 of the indicator decision 640determines a minimum time gap after which a pulse indicator can occur.The second stage 1104 determines whether the number of samples since thelast indicator is greater than the minimum allowed pulse gap. The thirdstage 1106 decides whether to generate a pulse indicator trigger. If notrigger occurs, a sample count is incremented. If an indicator triggeroccurs, the sample count is reset to zero.

As shown in FIG. 11, the first stage 1102 has a divider 1110, atruncation 1120 and a first multiplexer 1130. These components functionto set the minimum allowable gap between pulse indications. Under nodistortion, the minimum gap is 10 samples. Under distortion, the gap isdetermined by the pulse rate. Specifically, under distortion, theminimum gap is set at 80% of the number of samples between pulses asdetermined by the pulse rate input 401. This is computed as 0.8 timesthe sample frequency, 62.5 Hz., divided by the pulse rate in pulses persecond, or:

 min. gap=0.8×(60/pulse rate)×62.5=3000/pulse rate  (17)

The divider 1110 computes 3000/pulse rate. The divider output 1112 istruncated 1120 to an integer value. The first multiplexer 1130 selectsthe minimum gap as either 10 samples if the distortion input 622 is“false” or the truncated value of 3000/pulse rate if the distortioninput 622 is “true.” The selected value is provided on the multiplexeroutput 1132, which is fed to the second stage 1104. The second stage1104 is a comparator 1140, which provides a Boolean output 1142 that is“true” if a counter output 1152 has a value that is equal to or greaterthan the minimum gap value provided at the first multiplexer output1132.

FIG. 11 also illustrates the third stage 1106, which has a counter andan “and” function. The counter comprises a delay element 1150 providingthe counter output 1152, an adder 1160 and a second multiplexer 1170.When the counter is initialized, the second multiplexer 1170 provides azero value on the multiplexer output 1172. The multiplexer output 1172is input to the delay element, which delays the multiplexer output valueby one sample period before providing this value at the counter output1152. The counter output 1152 is incremented by one by the adder 1160.The adder output 1162 is input to the second multiplexer 1162, whichselects the adder output 1162 as the multiplexer output 1172 except whenthe counter is initialized, as described above. The counter isinitialized to zero when the pulse indicator trigger 409 is “true” asdetermined by the output of the “and” element 1180. The “and” 1180generates a “true” output only when the comparator output 1142 is “true”and the quality output 632 from the waveform analyzer 630 (FIG. 6) isalso “true.”

Visual Pulse Indicator

With motion, a plethysmograph displayed on a pulse oximeter is oftendistorted and may be obscured by artifact. With the advent of pulseoximeters that can accurately calculate saturation during motion, theplethysmograph alone is not a sufficient indicator of arterial pulses orsignal quality. A visual pulse indicator according to the presentinvention can supplement the plethysmograph display to identify theoccurrence of a patient's pulse and also indicate confidence in thecomputed values of saturation and pulse rate. The visual pulseindicator, shown as vertical lines coinciding with the peak of arterialpulsations, indicates a patient's pulse even when the plethysmograph isdistorted or obscured by artifact. The height of the vertical lineindicates data integrity. A high vertical line indicates confidence inthe saturation and pulse rate measurements, whereas a small vertical barindicates lowered confidence.

FIGS. 12-14 illustrate a visual pulse indicator generated in response tothe indicator trigger output 409 (FIG. 4) and indicator amplitude output410 of the pulse indicator 400 (FIG. 4). In FIG. 12, the top trace 1210is an exemplar plethysmograph waveform without significant distortion.The bottom trace 1260 is a corresponding visual pulse indicationcomprising a series of relatively large amplitude spikes that aregenerally synchronous to the falling edges of the input waveform 1210.Because the input waveform 1210 has low distortion, the pulse indication1260 is somewhat redundant, i.e. pulse occurrence and data confidence isapparent from the input waveform alone. Nevertheless, FIG. 12illustrates the visual pulse indicator according to the presentinvention.

In FIG. 13, the plethysmograph waveform illustrated in the top trace1330 displays significant distortion. In contrast to the example of FIG.12, pulse occurrence and data confidence is not obvious from the inputwaveform alone. The corresponding visual pulse indicator 1360, however,indicates pulse occurrence at the location of the display spikes.Further, the relatively large spike amplitude indicates high dataintegrity and a corresponding high confidence in the computed values ofpulse rate and saturation despite the waveform distortion.

In FIG. 14, the plethysmograph waveform 1410 also displays significantdistortion. In contrast to the example of FIG. 13, the visual pulseindicator 1460 displays relatively low amplitude spikes corresponding tothe latter half of the waveform sample, indicating relatively low dataintegrity and low confidence in the computed pulse rate and saturation.

Signal Quality Alert

FIGS. 15-16 illustrate the generation of a caregiver alert thatsupplements the visual pulse indicator described with respect to FIGS.12-14, above. When signal quality is very low, the accuracy of thecomputed pulse rate and saturation may be compromised and a caregiverwarning is warranted. The alert may be a display message, an alarmhaving a unique tone or some other form of visual or audible method ofdrawing the attention of the caregiver.

As shown in FIG. 15, a signal quality alert 1500 has an alert triggeroutput 1510 and integ 404, PR density 405 and harmonic ratio 1550inputs. Integ 404 and PR density 405 are described with respect to FIG.4, above. The harmonic ratio 1550 is derived from the ratio of theplethysmograph signal energy contained in frequency bands around theheart rate fundamental frequency and its harmonics divided by the totalsignal energy. The harmonic ratio provides a measure of signal qualitybecause most of the signal energy in an uncorrupted plethysmograph is atthe heart rate and harmonics. The plethysmograph spectrum and associatedfrequency measurements are described in U.S. Pat. No. 6,002,952, citedabove.

As shown in FIG. 16, the signal quality alert 1500 has an integrity(INTEG) comparator 1610, a PR density (PRD) comparator 1630 and aharmonic ratio (HR) comparator 1650. Each of the comparators 1610, 1630,1650 has a Boolean output 1614, 1634, 1654 that is asserted when aninput signal quality measure 404, 405, 1550 falls below a correspondingthreshold 1612, 1632, 1652. In particular, the INTEG comparator 1610 hasa low INTEG output 1614 that is asserted when signal integrity fallsbelow the INTEG threshold 1612. Also, the PRD comparator 1630 has a lowPRD output 1634 that is asserted when the PR density 405 falls below thePR density threshold 1632. Further, the HR comparator 1650 has a low HRoutput 1654 that is asserted when the harmonic ratio 1550 falls belowthe HR threshold 1652.

Also shown in FIG. 16, the comparator outputs 1614, 1634, 1654 arecombined with a logical AND to generate an alert trigger output 1510. Inparticular, the alert trigger output 1510 is a Boolean value assertedwhen all of the low signal quality outputs 1614, 1634, 1654 areasserted. In this manner, the alert trigger 1510 is responsive to acombination of signal quality measures 404, 405, 1550 and is triggeredwhen these measures all indicate a very low signal quality, asdetermined by the threshold inputs 1612, 1632, 1652. In one embodiment,each of the signal quality measures 404, 405, 1550 vary between 0 and 1,and the INTEG threshold 1612 is set at 0.3; the PRD threshold 1632 isset at 0.7 and the HR threshold 1652 is set at 0.8.

Although the signal quality alert has been described with respect to acombination of the signal quality measures integrity, pulse rate densityand harmonic ratio, the signal quality alert could also be triggeredbased upon other measures related to the level of signal distortion orcorruption, motion artifact, or noise. Further, although the signalquality alert has been described with respect to a logical ANDcombination of these signal quality measures compared with correspondingthresholds, various other combinations of these or other measuresrelated to the level of signal distortion or corruption, motionartifact, or noise could be used to trigger a signal quality alert. Forexample, an OR combination of signal quality measures each compared to adifferent threshold could be used to trigger an alert. As anotherexample, an arithmetic combination of signal quality measures could becompared to a single threshold to trigger an alert. As a furtherexample, the height of the displayed visual pulse indicator couldtrigger a signal quality alert if sufficiently less than full-scale,such as less than one-third full-scale.

Confidence-Based Alarm

FIGS. 17-18 illustrate a confidence-based alarm responsive tophysiological data, such as oxygen saturation or pulse rate. Theconfidence-based alarm 1700 according to the present invention isadapted to reduce the probability of missed true alarms during high dataconfidence periods and to reduce the probability of false alarms duringlow data confidence periods. As shown in FIG. 17, the confidence-basedalarm 1700 has as inputs physiological data (PD) 1710, signal qualitymeasure (SQM) 1720, and alarm threshold 1730 and an alarm trigger output1740. The PD input 1710 may be, for example, saturation or pulse ratedata. The SQM input 1720 may be data integrity, pulse rate density,harmonic ratio, or other measures or combinations of measures related tothe level of signal distortion or corruption, motion artifact, or noise.The alarm trigger 1740 initiates an audio and/or visual warning thatalerts a caregiver whenever the physiological data indicates a patient'svital signs are outside of acceptable limits, as set by the alarmthreshold 1730, for example a minimum saturation or a maximum or minimumpulse rate. There may be one or more alarms 1700 in a particular pulseoximeter.

As shown in FIG. 18, the confidence-based alarm 1700 has an PDcomparator 1810, a data buffer 1830 and a delayed PD (DPD) comparator1850. The PD comparator 1810 has PD 1710 and alarm threshold 1730 inputsand a PD limit 1814 output. The PD limit 1814 is a Boolean value that isasserted when the PD input 1710 exceeds, either above or below dependingon the physiological measure, the alarm threshold 1730. The data buffer1830 acts as a delay line, time shifting the PD data 1710 by a valuethat is a function of the SQM input 1720 to generate the delayed PD(DPD) data 1832. The DPD comparator has DPD 1832 and alarm threshold1730 inputs and a DPD limit 1854 output. The DPD limit 1854 is a Booleanvalue that is asserted when the DPD input 1832 exceeds the alarmthreshold input 1730, similar to the PD limit 1814. In an alternativeembodiment, the threshold inputs to the PD comparator 1810 and the DPDcomparator 1850 are set to different levels. The confidence-based alarm1700 also has a logical AND that combines the PD limit 1814 and DPDlimit 1854 outputs to generate the alarm trigger 1740. The alarm trigger1740 is a Boolean value that is asserted when both the PD limit 1814 andthe DPD limit 1854 are asserted.

Also shown in FIG. 18, the confidence-based alarm 1700 rejects thosefeatures of the physiological data PD 1710 that are below the alarmlimit for less duration than the data buffer 1830 delay, so as to reducefalse alarms. The probably of false alarms is reduced with increasingdata buffer 1830 delay. Generally, reducing the probability of falsealarms increases the probability of missed true alarms. Advantageously,the buffer delay is a function of a signal quality measure 1720, so thatthe probability of false alarms is reduced when signal quality is lowand the probability of missed true alarms is reduced when signal qualityis high.

FIGS. 19A-D illustrate the operation of one embodiment of aconfidence-based alarm according to the present invention. FIG. 19Aillustrates an alarm with zero delay. FIGS. 19B-D illustrate an alarmwith increasing amounts of delay. FIG. 19A is a chart 1900 having avertical axis 1901 of saturation (SpO₂) and a horizontal axis 1902 oftime. An alarm threshold 1906 is shown along the vertical axis 1901,corresponding to the alarm threshold input 1730 (FIG. 17). Depicted issaturation data 1910 corresponding to the PD 1710 (FIG. 17). An alarm isimmediately triggered when saturation data 1910 falls below the alarmthreshold 1906, and the duration of the alarm is the period of time thesaturation data is below the threshold 1906.

FIG. 19B is an identical chart 1900 as described above, but depictingdelayed saturation data 1920 corresponding to DPD 1832 (FIG. 18) that istime-shifted from the saturation data 1910 by a short delay 1940. Inthis example, both the saturation 1910 and the delayed saturation 1920are below the alarm threshold 1906 during a time period 1950. Duringthis time period 1950, the alarm trigger 1740 (FIG. 17) is asserted togenerate an audio and/or visual warning that a desaturation event isoccurring. The onset of the alarm is delayed 1940, as compared with FIG.19A. The alarm functions similarly to a low pass filter that smoothesthe saturation data 1910, preventing desaturation events that are lessthan the delay 1940 from triggering an alarm, as described with respectto FIG. 19D, below.

FIG. 19C is an identical chart 1900 as described above, but with thedelayed saturation data 1920 time-shifted from the saturation data 1910by a medium delay 1960. In this example, during the entire time period1970 when the saturation data 1910 is below the alarm threshold 1906,the delayed saturation data 1920 is also below the threshold 1906. Thus,the alarm trigger 1740 (FIG. 17) would be asserted and a warning wouldbe generated.

FIG. 19D is an identical chart 1900 as described above, but with thedelayed saturation data 1920 time-shifted from the saturation data 1910by a long delay 1980. In this example, at the time point 1990 when thesaturation 1910 rises above the alarm threshold 1906, the delayedsaturation 1920 has yet to fall below the threshold 1906. Thus, thealarm trigger 1740 (FIG. 17) would not be asserted and no warning wouldbe generated. FIGS. 19A-D illustrate that the effect of an increasingdata buffer delay is to increasingly delay the onset of the alarmtrigger 1740 (FIG. 17) and to increasingly filter-out or smooth arelatively short drop in saturation 1910, which may be a false alarmduring low signal quality conditions. Although the confidence-basedalarm 1700 (FIG. 17) is described above in terms of an alarm delay toreduce false alarms, where the delay is a function of signal quality,one of ordinary skill in the art will recognize that the scope ofpresent invention encompasses other mechanisms for reducing false alarmsthat are a function of physiological data confidence.

A pulse oximetry data confidence indicator has been disclosed in detailin connection with various embodiments of the present invention. Theseembodiments are disclosed by way of examples only and are not to limitthe scope of the present invention, which is defined by the claims thatfollow. One of ordinary skill in the art will appreciate many variationsand modifications within the scope of this invention.

What is claimed is:
 1. A data confidence indicator comprising: a plurality of physiological data and a plurality of signal quality measures derived from a physiological sensor output; a plurality of comparator outputs each responsive to one of said measures and a corresponding one of a plurality of thresholds; an alert trigger output combining said comparator outputs; and a low signal quality warning generated in response to said alert trigger output, said thresholds set so that said warning occurs during a time period when there is low confidence in said data.
 2. The indicator of claim 1 wherein said warning is a display message that supplements a visual pulse indicator, said display message specifying low signal quality when said visual pulse indicator has an amplitude less than one-third full-scale.
 3. The indicator of claim 1 wherein said signal quality measures comprise at least one of an integrity measure, a pulse rate density measure and a harmonic ratio measure.
 4. The indicator of claim 3 wherein said thresholds comprise an integrity value of less than 0.3, a pulse rate density value of less than 0.7 and a harmonic ratio value of less than 0.8.
 5. The indicator of claim 1 further comprising: a smoothing filter for said data; an adjustment for said smoothing filter that is a function of at least one of said signal quality measures; a predetermined alarm threshold for said data; and an alarm trigger responsive to said smoothing filter and said alarm threshold.
 6. The indicator of claim 5 wherein said filter comprises: a buffer having said data as an input and a delay output, wherein the delay output comprises said data time-shifted according to said adjustment; a first comparator output responsive to said data and said threshold; and a second comparator output responsive to said delay output and said threshold, said comparator outputs combined so as to provide said alarm trigger.
 7. A data confidence indicator comprising: a processor configured to derive a time-dependent physiological data set and a plurality of time-dependent signal quality measures from a physiological signal; a buffer configured to time-shift said data set by a delay to generate a delayed data set, said delay being a function of at least one of said signal quality measures; a threshold setting a limit for said data set and said delayed data set; and a warning generated when the levels of said data set and said delayed data set are beyond said threshold.
 8. The data confidence indicator according to claim 7 further comprising: a first comparator output responsive to said data set and said threshold; a second comparator output responsive to said delayed data set and said threshold; and a combination of said comparator outputs providing an alarm trigger for said warning.
 9. The data confidence indicator according to claim 8 further comprising a combination of said signal quality measures providing an alert trigger to generate a warning when confidence in said data set is low.
 10. A data confidence indication method comprising the steps of: acquiring a signal from a physiological sensor; calculating a physiological data set from said signal; calculating a plurality of signal Quality measures from said signal; indicating on a display a level of confidence in said data set based upon at least one of said signal quality measures; utilizing said signal Quality measures to detect a low signal Quality period during which time said data set may be compromised; writing an alert message on said display during at least a portion of said low signal quality period; comparing each of said signal quality measures to a corresponding one of a plurality of thresholds to generate a plurality of trigger inputs; and combining said trigger inputs to trigger a low signal quality warning.
 11. A data confidence indication method comprising the steps of: acquiring a signal from a physiological sensor: calculating a physiological data set from said signal; calculating a plurality of signal quality measures from said signal; indicating on a display a level of confidence in said data set based upon at least one of said signal quality measures; setting an alarm limit for said data set; filtering said data set to generate an alarm trigger based upon said alarm limit; and; adjusting characteristics of said filtering step according to said signal quality measures so that more filtering is applied during said low signal quality period.
 12. The data confidence indication method according to claim 11 wherein said filtering step comprises the substeps of: time-shifting said data set to create a delayed data set; comparing said data set to a threshold to generate a first trigger input; comparing said delayed data set to said threshold to generate a second trigger input; and combining said trigger inputs to generate said alarm trigger.
 13. The data confidence indication method according to claim 12 wherein said adjusting comprises the substep of changing the amount of said time-shifting according to said signal quality measures.
 14. A data confidence indication method comprising the steps of: acquiring a signal from a physiological sensor; calculating a physiological data set from said signal; calculating a plurality of signal quality measures from said signal; setting an alarm threshold for said data set; and delaying an alarm trigger when said data set exceeds said threshold as a function of at least one of said signal Quality measures so as to reduce the probability of false alarms, wherein delaying the alarm trigger comprises: time-shifting said data set by a delay to generate a delayed data set, wherein said delay is a function of at least one of said signal quality measures; comparing said data set to said threshold to create a first limit output; comparing said delayed data set to said threshold to create a second limit output; and combining said limit outputs to generate said alarm trigger.
 15. A data confidence indication method comprising the steps of: acquiring a signal from a physiological sensor; calculating a physiological data set from said signal; calculating a plurality of signal quality measures from said signal; setting an alarm threshold for said data set; delaying an alarm trigger when said data set exceeds said threshold as a function of at least one of said signal quality measures so as to reduce the probability of false alarms; comparing each of said signal quality measures to a corresponding one of a plurality of thresholds to generate a plurality of trigger inputs; and combining said trigger inputs to trigger a low signal quality warning. 